Ross Woods, rev. Feb '11, Dec. '17
Many people with serious problems don't ask for help, even if they urgently need it. But they might come into contact with you about some other problem. You might be the only person who could identify their problem and get them help, even if their problems are outside the expertise or interests of you or your organization.
Harvey works for an employment agency, and Jenny comes in about a job. During the interview, Harvey notices that Jenny seems to have a substance abuse problem. He tactfully brings it up and tells her that he doesn't know all that much about it. They talk about it for a while and Jenny eventually says she'd like some help. But she's embarrassed and thinks she might be able to cope on her own.
Harvey mentions Barry, a guy he knows who runs an organization called InnerCity, and they could help her. Harvey offers to refer her, and Jenny reticently agrees. Harvey phones up and talks to Barry at InnerCity. He then passes the phone over to Jenny and Barry sets her at ease. They make a time to meet at InnerCity and exchange some contact details.
Harvey says that, if she doesn't mind, he'd like to know how the meeting goes. He knows it's easy for people to have second thoughts and simply not show up.
You need to help clients to address problems other than those they came to you about. You'll also need to decide whether to refer or retain the client, and whether a brief intervention is appropriate instead of an immediate referral. Then you have to help the client accept your response.
These clients with secondary issues are most likely to present first to juvenile justice, youth service, social housing, child protection or an employment service for an issue relevant to those services. But even if you work in other fields, you will still need to pick up on non-presenting problems.
You could identify harm, neglect, abuse or risk of harm, and harm can be physical, emotional, cognitive, psychological, sexual or financial.
The kinds of problems you are most likely to pick up are:
The procedure for a response follows these steps:
As an organization, you need to prepare in several ways before you can successfully handle these kinds of interventions.
Check that you have procedures in place before you start. In particular, you need a procedure for reporting routine contacts with clients, such as a journal or a system of case notes. You’ll also need a framework for handling serious incidents involving difficult behavior. You might have to inform someone orally at the time, but there should be a form for reporting incidents in writing. Some procedures are not written down, especially in smaller organizations. They are the normal "how we do things here" that are taught to new staff.
Check that you have a procedure for addressing duty of care and legal requirements in responding to indicators of risk of abuse, neglect or harm. For example, you might be subject to mandatory reporting. Besides, you might have a wider duty of care than you think for people in your care who are not mentally competent.
The specific procedure for giving referrals is described in "Your referral list."
Policies and procedures have various purposes:
If there could be legal consequences, get your procedures checked for legal implications. In particular, they need to reflect your duty of care. For example, if you might have to physically restrain someone who is being dangerous, you need to know how to exercise your duty of care without being booked for assault.
Assessment tool
You should have an assessment tool to assess the level of risk to the client and others involved. This kind of assessment is quite different from the normal ""How much harm? and "How probable is it that it will happen?" The reason is that you already have signs of risk or harm. The "tool" will likely be a set of questions or criteria such as the following:
Assessment of suspected harm or risk
To be read in conjunction with intervention and referral procedures
Assess the case using the following questions:
Decide on one of the following options:
You are probably accustomed to having clients showing up at your organization for the kind of help you provide.
First, greet the client normally and communicate with clients in a way that will establish a trusting and respectful relationship. Help the client to identify the areas of concern that they came to see you about, and plan what you will do for them. You'll use your normal questions, observations, and assessment tools to identify possible presenting issues.
If you are working with clients from another culture, you'll need to fit in with their cultural obligations e.g. family roles.
You also need to pick up on any non-presenting problems or issues. Part of your role is to identify harm, neglect, abuse, or risk of harm. This is wide-ranging because harm can be physical, emotional, cognitive, psychological, sexual, or financial.
Pay extra attention to the groups of vulnerable people at highest risk. They tend to be:
Look for any signs of harm, neglect, abuse or risk of harm:
Be aware that those inflicting harm may may be the carers, service providers, the client themselves, family or significant others, or other members of the community,
If you suspect that the client has other issues, your first step is to check the available information. You can easily check your client files and case notes, and ask your colleagues. Your organization might have procedures for collecting and analyzing client information. They could be either written or oral. Ask about questionnaires, assessment tools and client profile forms
You are looking for information on the client's behaviour, their physical appearance and acuity, their answers to questions, and other information provided by client and information on the client provided by family, carers, other workers, or other agencies
As you go, you might also be able to gather information from the client's family or carers, your files of the clients, your colleagues, or from other agencies with knowledge of the client.
Based on your information, ask the following questions:
Use your information to decide on a suitable course of action. First, use your organization's assessment tools to assess the level of risk to the client and others involved. The assessment might indicate that you should discontinue the process.
If you need to continue, consider the following questions:
A brief intervention is a contact with a client when the worker addresses a client's problem by immediate referral. All team members should be able to do a brief intervention, because it needs to happen when the opportunity strikes.
You can provide a brief intervention yourself if:
When you intervene, do it one-to-one in private to keep your conversation confidential. Having physical and visual barriers will also contain it if the client become angry and it becomes a crisis. The intervention needn't take long but reduces harm and helps change behaviour.
Focus first on encouraging and motivating the client, giving some emotional support, and de-escalating any tension. Take the opportunity to discuss the matter with the client, but be friendly and sensitive. Sensitive questions, reflective listening and non-confrontational body language will help. Do what you can at the time to reduce harm and risk, and encourage them to change behavior. You might also need to offer carer respite (e.g. for clients with ABI) questioning, reflective listening and body language.
Be aware that the client may be shy or embarrassed about the issue. Is some cases, they might feel in danger if they tell you. For example:
Work with the client to develop a plan and get them to commit to it. Help them to make informed decisions. Tell them about the options and services available to them to address their issues, and help them to think about making changes to improve their well being. Give them resources as appropriate (e.g. contact details of people or organizations, brochures and information sheets, appointments with specialists). And don't forget, carers may need respite care.
You might find that the client becomes difficult or challenging, and you should be prepared to avert a crisis. Don't let the problem get worse. For example, you can identify and address the source of the issues and discuss the situation with the client in a way that calms them down. Be careful to contain emotional responses and escalating behaviour, both your own and theirs. You may need to negotiate to prevent escalation, mediate with other people, or give an immediate referral. But if it looks like it might get out of hand, get help from other workers or client carers. In the worst case, you might have to intervene to ensure physical safety.
A mindset of powerlessness is most difficult to understand if you aren't powerless. It leads people to accept an unfair lot in life.
The symptoms of powerlessness include:
Powerlessness is only perceived in some cultures; people simply need to be taught their rights and their role in the decision-making system.
But powerlessness is real in some cultures, where marginalized people are deliberately kept in place by government law, bureaucrats, large companies, traditional law, or social stigma.
Powerlessness is closely related to cultural poverty. Cultural poverty means that people can be acculturated to practices that keep them poor. (It does not mean that they have no culture.) Even if you offer a solution to people's problems, they might culturally find it difficult to accept.
In other words, disadvantage is part of their culture. Look at these examples:
As a community services provider, the implications of cultural poverty for you are:
Multiple risks need special attention. In particular, children, particularly infants, are at higher risk of harm in families where there is abuse of alcohol and other drugs. They are at even higher risk if there are other risk factors such as domestic violence and mental health issues.
You need to identify complex cases early. In the community services sector, they are generally defined as:
Some organizations or industry standards require three or more of the above "complex" factors to be considered high risk. Other guidelines suggest that any one of them could be adequate grounds for residential care, in particular:
In children's work, complex cases can include factors such as:
Different kinds of problem areas need different approaches, so the agencies that treat them have different methods, values, and philosophies. This list is not at all comprehensive. Besides those mentioned below, you might also find disability, homelessness, and unemployment.
People can acquire permanant brain injury through accidents to the head or a lack of oxygen to the brain. People with addiction issues also have brain injury, but it is not normally permanent. You should:
You may need to know how to minimize harm and recognize the effects of AOD on the body and on social relationships, and of the signs and symptoms of intoxication.
You'll need to know groups and agencies in the community who can respond to individuals with AOD problems by providing treatment and detoxification programs. Also important is an awareness of personal bias, and models or perspectives on drug use (i.e. disease perspective, moral perspective of both the client and of referral agencies).
You will need to know of groups and agencies in the community that can detoxify and treat individuals with AOD problems.
Some people will have a personal bias toward some agencies and against others. If you refer people to AOD agencies, you need to check that the agency you refer to follows a philosophy that you and your organization can agree with, and will suit the client being referred:
Different kinds of drugs have different physical effects, and they vary according to how much they were used. They generally induce malnutrition and poor health if used for long enough. Some are diet suppressants while others bring on obesity.
Most addictive drugs tend to make people behave erratically and manipulate people, both of which tend to alienate them from other people. Some drugs eventually produce psychosis and paranoia.
The signs of alcohol intoxication are slowed reactions, slurred speech, and poor physical coordination.
When working with adult clients who have children, you must include the safety, welfare and well-being of the children in all case management practices.
Things to watch out for relating to children:
Mandatory reporting
Child protection requires knowledge of relevant state mandatory reporting legislation and its application. For example, In Western Australian mandatory reporting applies to doctors, nurses and midwives, teachers (i.e. anybody registered under WACOT), teachers in community kindergartens, teachers in detention centres, and police officers.
The mandatory reporter must report suspicions of child sexual abuse to the Department for Child Protection if they form this belief, based on reasonable grounds, in the course of paid or unpaid work. They should also report other forms of abuse (physical, emotional and neglect), but there's no penalty if they don't.
Child sexual abuse includes sexual behaviour in circumstances where:
Child protection also requires knowledge of child development, dynamics of child abuse, risk factors, behavioural/physical indicators of abuse and agencies that respond to child protection matters. (See the separate unit Identify and respond to children and young people at risk)
You can be required to report under other conditions too, such as:
Developmental disability includes difficulties learning, thinking and reasoning, retaining information and forming social relationships.
It is vital to recognize clients' individuality, their right to age appropriate consultation and to self determination. You also need to recognize needs arising from any social isolation and the critical importance of primary care-givers in their lives. You need to know groups and agencies in the community that can provide advocacy services. (Keep a list of contacts.)
Domestic violence occurs across all groups, cultures and creeds, and is often an abuse of power perpetrated both in a relationship and after separation. It takes a number of forms:
The safety and well being of victims should be your primary concern. This often means that women need help to move directly into a refuge.
You need to know the groups and agencies in the community who can respond to individuals with domestic violence issues.
The most common financial problem is unpayable debt, especially relating to credit cards. Other financial problems are lack of tax reporting, and problems with banks.
Problems with social services (Centrelink) are most common. Medicare is also a possibility.
You will need to know about juvenile justice according to your role. You may need to know:
You need to be able to recognize how vulnerable young people are when dealing with authority. You should also recognize the protections that should operate during an investigation or proceeding in relation to an offence.
Keep a list of contanct in agencies in the community that can provide advocacy and legal services for young people dealing with the justice system.
This may include civil issues such as custody of children or court orders. You may wish to refer the client to legal aid.
Legal problems can also include offences that could be prosecuted, such as harassment, threat of violence, criminal damage, or possession of illicit substances.
If the offence is subject to mandatory reporting, you have no choice but to report it. If it brings physical danger to people on your premises, then under your OHS obligations, you may need to get police help. (In some job roles, violent clients is a major OHS risk.)
Otherwise you face the ethical dilemma of having to decide how to act in the best interests of your client.
You may need to recognize basic signs and symptoms of anxiety, depression, erratic behavior, suicidal impulses, and indicators of mental illness such as hallucinations or delusion. You need to know of suitable referral and intervention services in the community.